Boots, utes and liver failure

INTRODUCTION: Exertional heat stroke (EHS) is a diagnosis of military significance given the hot and humid operational environments coupled with potential for poor outcomes if not diagnosed and treated timely We present a case of EHS in a service-member (SM) resulting in acute liver failure (ALF) CASE DESCRIPTION/METHODS: A 34 year-old SM with a past medical history significant for severe alcohol use disorder who presented with EHS after going on a 3-mile unit run in 'boots and utes ' The SM was noted to have slurred speech and confusion afterwards prompting a visit to the ED On initial evaluation he was noted to be obtunded with hypotension, tachycardia and a core temperature of 104o F Following initial care with external cooling, the SM was transferred to our ICU and began to show signs of multi-organ dysfunction including acute encephalopathy, myocardial injury, acute kidney injury (AKI), anion gap metabolic acidosis, rhabdomyolysis, disseminated intravascular coagulation, and fulminant liver failure with AST/ALT of 16,400/4,820 respectively Recognition of ALF secondary to EHS prompted our care team to refer the SM to a liver transplant center to be evaluated for an orthotropic liver transplant DISCUSSION: According to the Armed Forces Health Surveillance Branch's annual update, 12,361 service members were reported to have heat related illness in 250 US military installations worldwide Our case presents a SM with multiple risk factors for EHS including chronic alcohol use and deconditioning during the COVID-19 pandemic that lead to the development of ALF despite prompt diagnosis and treatment Of note, literature review states that ∼5% of heat stroke casualties experience ALF Pathogenesis of ALF is thought to be secondary to a combination of direct thermal injury, gut ischemia from shunting of blood to the periphery and an inflammatory response from bacterial toxins translocated from the ischemic gut Multiple prognostic risk assessments are used including the Model for End stage Liver Disease (MELD) and King's College Criteria to assess benefits of liver transplant Our patient, despite only fulfilling 2 of 4 of the King's College Criteria, had a MELD score of 39 indicating a 52 6% 3-month mortality indicating a need for liver transplant